OIG Report Highlights Issues in Medicare Advantage Risk Payments

The HHS Office of Inspector General (OIG) released a report on October 24 that addresses the ongoing issues related to the Medicare Advantage (MA) program, particularly concerning the use of Health Risk Assessments (HRAs). The report highlights that an estimated $7.5 billion in risk-adjusted payments for 2023 has been linked to diagnoses reported solely based on HRAs and related chart reviews without any accompanying service records. The findings suggest that either the reported diagnoses may be inaccurate, leading to improper payments, or that enrollees did not receive necessary care for serious conditions identified only through HRAs.

To address these concerns, the OIG proposed three recommendations to the Centers for Medicare & Medicaid Services (CMS). These include imposing stricter restrictions on utilizing diagnoses from in-home HRAs for risk adjustments, conducting audits to validate such diagnoses, and examining if certain health conditions linked to the in-home HRAs are more prone to misuse among Medicare Advantage Organizations (MAOs). The implications of this report underscore the need for greater oversight and accuracy in the Medicare Advantage program to ensure that enrollees receive appropriate care and that federal funds are not being misallocated.